Debt for Cash-The Grinch Returns! 11:09 PM

We have made it through another rough year folks, now the season turns cold with a little snow on the horizon. This Christmas we can be thankful for all we have, our families, our wives and husbands, our children, our health and freedom- but I think we can be a little Grinchy about the costs we have paid in cash, jobs and homes for the spending of a few well placed influential's. This holiday season, we should reflect on our losses and how to prevent them in the future, our kids will thank us if we set them upon the rock instead of on the sand.

The past is no predictor of the future- but since we must live through the future and the past has already been done, we need to look back, we should not make the same mistakes twice, or three times. It is uncomfortable but once we do it we can move on to create the world we all wish to live in and pass on to our grand-kids.

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We have hear various figures on this one most often 11 trillion dollars, but we have to factor in all our public held debt, contractual requirements, Social Security and Medicare. This total figure of what needs to be paid sooner or later is about 56.4 trillion. Sound like a lot- it is. For a further explanation just click on this link from the Peter G. Peterson Foundation

If you feel your more of the traditional type regarding our national debt numbers you can head over to our National Debt Clock which as I type is now at 12.06 trillion- of course it rises so fast that by the time I finish this sentence its gone up a few million dollars. The clock is flash based so you can see the numbers jump in real time. A few interesting points about the clock is our debt held by foreign countries which is at 3 trillion and each persons held liabilities which is about 345 thousand- our estimated personal assets are only 242 thousand. Yes- there is the trade deficit too .

Of course we as individuals have much to blame on ourselves, in 2007 we actually out spent the amount of our gross domestic product, all funded by credit- we know how that story ended. The chart below was excerpted from NPRs Planet Money

Figure © 2009 NPR-

NPR does not promotes or endorse any third party's causes, ideas, web sites, products or services.

In terms of where we rank with the debt each person holds we are ranked 14th on a complied list of 188 above Australia and below Finland, the UK ranks 3rd with debt per capita held. For the complete chart click here- NationMaster.com

Today a bachelors degree does not command as much income anymore, the odds of a person who has a bachelors makes is in 25 to 35 are making less than the poverty level are 1 in almost 24- this according to the Book of Odds

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The world has much so much poverty we need to take a look at how this is related to health and life expectancy. This chart was created from the World Bank. Pay particular attention to the blue spheres, those countries have the poorest population with the shortest live expectancy. Poverty is related to life expectancy worldwide including at home in America- more on that in another blog article.

Figure © 2009 World Bank Group -

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You buy a cup of coffee and a bagel before you go to work do you ever think about how much that costs, maybe 2.00 to 3.00 dollars? What can you do with 3 bucks? According to the World Bank and included in an article at the site Globalissues.org half the world lives on 2.50 dollars a day. Consider this as well: We spend more on cosmetics in the US that the world does on achieving basic education its poorest, 8 billion US dollars on cosmetics vs. 6 billion for basic education in developing nations- also taken from Globalissues.org

According to the Food and Agriculture Organization of the United Nations, currently there are more than 1 billion people in the world who are hungry every day.

Figure © FAO, 2009- Hyperlinks to non- FAO Internet sites does not imply any official endorsement of or responsibility for the opinions, ideas, data or products presented at these locations.

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Current bank right-down estimates for 2007 through 2010 as a result from our so called toxic assets (remember we live in these toxic asset houses and raise families but…) in an article by Reuters is estimated to be 1 trillion for the US and 1.6 trillion for the EU .

According to CNN’s Money and Main Street we lost approximately 1.3 trillion worth of wealth right from our pockets due to the depress- I mean recession.

According to Bread.org 16,000 children each day in the world die from hunger related illnesses. That sobering statistic also from Bread.org originates from a journal article written for the theLancet.com

In an article by Unicef there are more than 140 million children from the ages of 6 to 11 in the world that do not go to school and school of course is one way to escape poverty. It would take 6 billion a year to put keep these children in school which according to Unicef in 1997 is less than 1% of the money the world spends on weapons.

In another Unicef report over 2 million children die each year due to poor water quality and lack of sanitation. For that article click here as well.

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Average level of debt a US student graduates college with 21,000 dollars- taken from moneycentral from msn.

Average level of medical debt for those who filed for bankruptcy is 12,000 dollars- taken from fixourhealthcare.ca.gov

Average level of consumer credit card debt 5,612 dollars, but that is down some from last quarter- taken from prnewswire.com

So how did the world get this way- we over spent on everything, priorities and non-priorities. In a world of limited resources we (the world) not just America, borrowed from the wealthy, billions of people owe trillions to millions. Those who lent money and resources also borrowed to lend more than they could otherwise from those with still more resources. At some point the cycle becomes unmanageable, which is what we are beginning to see. What is different about today’s recession that did not occur during the great depression, many more people in the world and a greater ability to do more harm to them or more good for them. How do we reduce this debt? Simple, we learn live within our means, with moderation and return to the values of sharing.

Remember during this holiday season it is always easier to share than to have it taken out as taxes.

What about the few who hold all this debt: Careful of those who rule in high places, the last thing we should do is spend our way out of this recession- look at the messengers, isn’t that how we put the chains on in the first place?

Squeezing Money from a Health Care Stone 10:21 PM

Ambitious global attempts have been undertaken to analyze many countries' healthcare systems to document what has facilitated positive change and what has not. Everyone then armed with the data sit and pour over the stacks of paper to figure out how to better our healthcare system and suggest policy. Once it gets to the sub-committee though it dies a slow death to be transformed into some would say pork or other type of species the public would rather not look at.

One such an attempt to dig into the world health care systems is the World Health Report of 2000 which used weights to create an index of quality care. Using a composite of the twelve most industrialized nations they tabulated results and ranked them. Based on how well their health system works Greece ranked 14 with universal access and national healthcare services, the United States ranked 37 with variable access and supplemental insurance and Brazil ranked 125th with universal rights but contracted and national services. The US had a rank of 7th out of 12 that encompass a national system of healthcare, but those of higher ranking invariably provide universal healthcare while the US does not.

Statistical infant mortalities also have been used as a measure of healthcare effectiveness in a country as well. Infant mortalities in studies have been measured comparatively while in other studies within countries. In Australia, it was found that the lowest two classes set above the bottom class had 23% of the total infant deaths. These were the semi-skilled and skilled working class, and not the poorest unskilled. If you think about it his has implications for the US because these classes of people, who are also within the United States, are unlikely to be poor enough for US social insurance policies but not rich enough to afford healthcare. By implication if we have a very high infant mortality and 45 million are uninsured then infant mortality is a very good indicator of those who were poorer and uninsured, but employed with an income great enough to not be eligible for state run insurance.

In other words if similarities exist among certain countries and situations with their people then you can be certain that the statistics do not lie. You cannot fight statistics, except through misinformation and fear of change.

Unfortunately, the US links together voluntary insurance with private employer insurance and social insurance to provide healthcare coverage with the largest social insurance coverage administered through Medicare and Medicaid for a total of 17.3% of the US healthcare expenditures in 2000. Each country that has mixed coverage healthcare benefits have one common detriment in that all have issues ensuring quality on all the levels the mixture provides and in cost effective means, hence the current debate on universal healthcare and cost.

Everyone wishes for high quality healthcare but measuring the quality of care and improving it can be difficult to quantify. Continuous quality improvement, total quality improvement and the ever present process re-design are just a few of the many methods available to a healthcare systems management. But how can hospitals and other large clinical facilities find the money necessary to re-design ageing buildings, and retrofit older EHR/HIT systems, or throw them out and upgrade complexly? If we rank 37th in how our health system provides for its citizens but we spend the most per capita on health care where is all this money going? Hospitals are not receiving this money, their rates from Medicare, Medicaid and HMO insurance have been cut progressively over the years. In a few words: Follow the bread crumb trail of current health insurance commercials back to the source. While watching the news count how many health advocacy commercials and the words they use are for or against universal healthcare, note words such as experimental and government run are used.

A partial explanation of how costs are incurred by a hospital and how they are locked into a poor revenue stream is noted below:

In any organization, some aspects of the entity will drive costs and other parts will drive revenue. In a healthcare organization, cost centers generally do not have contact with clients and therefore are likely to induce costs without providing the corporate entity with income, that is the hospital. Most hospital expenses are fixed until a set point when new staff, equipment or even facilities are needed which creates a credible reason for strategic planning. Hospitals are constantly planning, why? They have very ridged streams of income but it is predictable so planning for new equipment, more staff or technology updates can be estimated for and monies can be allocated over time. There is little in the way of providing profitability to the organization except for fee services and perhaps donations. But, donations are down and fee for service has just about vanished into a relic.

A few ways hospitals are getting by with less is the electronic storage of documents and data; paper charts have to be stored while electronic charts can be expanded indefinitely and shared among facilities within the system. Electronic data has the capacity to be readily available and the details of the raw information can be adjusted for the specific treatment of each patient and return patients. One such very successful system was implemented by the U.S Military, AHLA which services 9 million patients through TRICARE.

Sadly, sometimes an economic loss cannot be contained with technology, restructuring or otherwise and divestment or a selling off of unprofitable components of the organization can occur.

1 stone = 6.35029318 kilograms

With efficient patient scheduling for appointments cost savings can result as well. There are many methods to schedule appointments, some being: standard, wave, resource-based, and open access scheduling. To facilitate payment to the physician or physician group, or reimbursement for services from insurer, CPT coding is used as well as statistical implications for payment on the insurer side such as usual, customary, and reasonable payment schedules, dictated by the data the insurer obtains over time in a geographical area. So this is being creative, squeezing money from the stone. So who are the people and organizations not being creative?

In 2000 we spent 4,499 dollars per person on health care but in 2001 as quoted from the book Health Care Administration: Planning, Implementing and Managing Organized Delivery Systems: 4th ed by Lawrence F. Wolper, 48 million Americans were without health insurance. In 2000 Medicaid accounted for 15.6 percent of all health care costs, while Medicare accounted for 17.3 percent of all health care costs for that year. In the year 2000 out of pocket health expenses comprised a total of 15.3 percent of total health care expenditures for that year. Ask yourself, “Where all the other health care expenditures came from, how were they paid and by what organizations?” and “Why were so many people uninsured then and are now?”

Why are hospitals doing without, our infant mortality so high. In 2004 our infant mortality rate slipped again to 23rd in the world. Why do we spend 10 to 20 percent of our personal income on our health care bills-the out of pocket costs and premiums? It should be noted that these costs are not associated with Medicare and Medicaid, they are from employer HMO sponsored plans. Why are 100 hospitals cutting more than 50 doctors and staff at a time when we spend so much? Hospitals are hurting, we are hurting, who or what organizations are not? What organizations have had enough cash to provide lots of health care commercials during your news hour? Again a link brought up on an early post that shows how hospitals are hurting in this recession. See the bottom link on going lean for other ways hospitals are getting creative or rather money from the stone: AMA Hospital Crisis

Hospitals Going Lean

Health Reform

APHA Infant Mortality

EHR/HIT done right and save too! 2:03 AM

Ever suffer from too much paperwork, I thought about it a few days ago and then I pulled my file on how some health care facilities solved theirs. AND WE THINK WE HAVE PAPERWORK! WOW!

Banner Health, a hospital system in Phoenix, Arizona was so convinced that the uncoordinated systems that they originally had in place, was not working for them that when they built their new hospital they purposely attempted to standardize all policies. Hospitals generate lots of paperwork, then need to for your records. Banner Health knew that the old methods of workflow were not consistent among departments and so during the building of the new facility they began the revamping of their system, while closely working with input from their clinicians. There is no one universally implemented computer system for hospital automation, their are some at the forefront but often its very difficult to work them into an expanded hospital. Many hospitals started small, but over time they grew as the needs of the community grew. So too the technology and the ability to help people recover did as well. So goes the build up of differing systems in a hospital and lots of paperwork. How a new system starts is by workflow modeling,

The modeling of prescription workflows or other complex systems requires tools, like any other thing we build, analysis and a requirement to develop testable and repeatable error free logical arrays, or decision points that are not redundant or return errors when can come back coded later on into software applications a hospital could use. Some of these tools are linguistic analysis and UML. One specific UML modeling tool is Rational Rose. IBM makes Rational Rose.

First, the existing business model that the stakeholders wish to modify is analyzed. Stakeholders could be doctors and nurses Once the previous system is analyzed, the new system is built from building blocks of predefined type. What is to be kept or left from the old system is a decision for the modeler and the stakeholder’s decision to make. The modeler is the professional software designer that was hired to build the new electronic health record system, or any other healthcare system. That which is kept from the old system is included in the new through building blocks as well. These predefined building blocks could be human activities, system or computer processes and decision points. Because the modeling of health care systems involves many systems and many constituents it is often called enterprise modeling. Enterprise modeling most often involves a facilitator who in a chauffeured manner drives the modeling process forward. The chauffeur typically uses modeling tools, such as computers, modeling software and other tools such as simple drawing mechanism.

When Banner Healthcare was building their new hospital they drew up new software for the building to be equipped with and the clinicians to use. One of the things they focused on was the modeling and modification of prescription workflows in their hospitals. Banner Health Care with input from doctors, nurses, administration, IT and other staff was able to alter 92 of its internal processes in a dozen core areas. Banner Health care was able to change processes across departmental lines and interactions that occur between multiple departments.

Between January and June 2007 Banner Estrella Medical Center had 29.9% fewer medical error claims as well as 71.8% lower costs due to those lower claim rates. Banner Estrella had 15.8% fewer nurses leaving the hospital system once the new EHR system was in place as well as 15.8% less cost associated with replacing the nurses who left the hospital system. Banner Estrella had 5.3% less costs incurred for overtime expenditures, 17.8% lower pharmacy and drug costs and a 95.6% lower cost in document storage per 1,000 persons. These safety and overall efficiency increases amounted to a 2.6 million dollar savings due to overall efficiency increases from January 2006 to June 2006 of that year. Ninety-five percent less cost on paper, neat!

St. Jude Children’s Hospital is another example. St. Jude has implemented the Open Clinical Foundation program which stores electronic medical records, a data storage facility, Powerchart which allows users to access data by a graphical interface, and Discern Expert which lists searchable details on best clinical practices, all use built-in clinical based rule systems. Moreover, EHR’s, when fully implemented lower medication error rates. With Banner Estrella Medical Center in Phoenix, quality, safety and efficiency metrics were used to define how their new EHR/HIT systems affected their hospital systems as well as patient care. Avoidance of adverse drug events, reduction in medical claims, increases in nurse retention, overtime reduction, pharmacy costs and document storage costs reduction were found during the study period between January and June of 2006. St Jude and Banner Estrella are examples where EHR’s was adopted whereby, IT not only created safer hospitals, but helped patients get better faster, with less cost for everyone. That's not bad at all. Hats to St. Jude Children’s Research Hospital, Banner Healthcare and IBM for Rose.